NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
Question 2 of 5
A client has returned from having a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
Correct Answer: B
Rationale: Bright red urine with many clots indicates significant bleeding post-prostatectomy, requiring immediate reporting. Normal output is 40-50 mL/hour, dark red urine with few clots is expected, and pain med requests are routine.
Question 3 of 5
The family of a 48-year-old woman who has multiple sclerosis and spends most of her time in bed or in a chair asks the nurse why they have been told they should have her take deep breaths and cough frequently. What should the nurse include in the reply?
Correct Answer: A
Rationale: Immobility in multiple sclerosis increases pneumonia risk; deep breathing and coughing mobilize secretions, preventing respiratory infections.
Question 4 of 5
The nurse recognizes which of these symptoms as characteristic of a panic attack?
Correct Answer: A
Rationale: panic disorders are characterized by recurrent, unpredictable attacks of intense apprehension or terror that can render a client unable to control a situation or to perform simple tasks; client can experience palpitations, chest pain, shortness of breath, a decrease in perceptual field, and a fear of 'losing it' or going crazy
Question 5 of 5
The nurse is planning care for an adult who has myasthenia gravis. What should be included in the care plan?
Correct Answer: B
Rationale: Myasthenia gravis causes muscle weakness, risking aspiration; checking gag and swallowing reflexes before eating ensures safety, unlike bathing or activity timing.